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Akamatsu H, Kohno Y, Hashizume J, Nakagawa H, Kodama Y, Kawano H, Maemura K, Ohyama K. Effect of rifampicin administration on CYP induction in a dermatomyositis patient with vasospastic angina attributable to nilmatrelvir/ritonavir-induced blood tacrolimus elevation: A case report. J Infect Chemother 2024:S1341-321X(24)00035-7. [PMID: 38360184 DOI: 10.1016/j.jiac.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
Ritonavir (RTV), which is used in combination with nilmatrelvir (NMV) to treat coronavirus disease 2019 (COVID-19), inhibits cytochrome P450 (CYP) 3A, thereby increasing blood tacrolimus (TAC) levels through a drug-drug interaction (DDI). We experienced a case in which a DDI between the two drugs led to markedly increased blood TAC levels, resulting in vasospastic angina (VSA) and acute kidney injury (AKI). Rifampicin (RFP) was administered to induce CYP3A and promote TAC metabolism. A 60-year-old man with dermatomyositis who was taking 3 mg/day TAC contracted COVID-19. The patient started oral NMV/RTV therapy, and he was admitted to the hospital after 4 days because of chest pain and AKI. On day 5, his blood TAC level increased markedly to 119.8 ng/mL. RFP 600 mg was administered once daily for 3 days, and his blood TAC level decreased to the therapeutic range of 9.6 ng/mL on day 9, leading to AKI improvement. Transient complete atrioventricular block and nonsustained ventricular tachycardia were present during chest pain. In the coronary spasm provocation test, complete occlusion was observed in the right coronary artery, leading to a diagnosis of VSA. VSA and AKI are possible side effects of high blood TAC levels caused by DDI, and attention should be paid to cardiovascular side effects such as VSA and AKI associated with increased blood levels of TAC when it is used together with NMV/RTV. When blood levels of TAC increase, oral RFP can rapidly decrease TAC blood levels and potentially reduce its toxicity.
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Affiliation(s)
- Hayato Akamatsu
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yusuke Kohno
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Junya Hashizume
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; Department of Medical Safety, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Hiroo Nakagawa
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yukinobu Kodama
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Kaname Ohyama
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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Zhang C, Ren X, Liu Y, Huang L, Feng Y, Zhang X. Effects of Wuzhi Capsule on Whole-Blood Tacrolimus Concentration Levels: A Systematic Review and Meta-Analysis. Ther Drug Monit 2024; 46:33-41. [PMID: 38150711 PMCID: PMC10769163 DOI: 10.1097/ftd.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/14/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Wuzhi Capsule (WZC) is a traditional Chinese medicinal herb widely used to treat drug-induced hepatitis or liver dysfunction and is usually prescribed in China to increase tacrolimus concentration. Several studies with small sample sizes have shown that WZC can increase tacrolimus concentration levels in clinical practice. This study aimed to evaluate the effect of WZC on whole-blood tacrolimus concentration levels and safety. METHODS We searched 7 databases for randomized clinical trials (RCTs) and observational studies (OSs) comparing whole-blood tacrolimus concentration levels between WZC and non-WZC treatments. Data analysis was performed using Review Manager version 5.3. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. RESULTS Eleven studies involving 6 RCTs and 5 OSs were included. The meta-analysis indicated that whole-blood tacrolimus concentration levels in the WZC group was significantly higher than that of the non-WZC group [weighted mean difference = 1.38, 95% CI (confidence interval), 1.21-1.56, P < 0.001], and similar results were shown in all the subgroups of follow-up time, different primary disease, and different WZC doses. In the self-control OSs, the whole-blood tacrolimus concentration levels in the WZC group was significantly higher than the non-WZC group (weighted mean difference = 1.17, 95% CI, 0.71-1.64, P < 0.001). WZC was generally well tolerated and there was no significant difference in the incidence of adverse reactions between the 2 groups. CONCLUSIONS WZC can increase whole-blood tacrolimus concentration levels. This may be an economical and practical treatment choice for patients, especially those with poor oral tacrolimus absorption capabilities. Nevertheless, RCTs and OSs with large sample sizes and high quality are needed in the future to confirm these positive results.
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Affiliation(s)
- Chunyan Zhang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Xiaolei Ren
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Yi Liu
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Lin Huang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Yufei Feng
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Xiaohong Zhang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
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Yamamoto N, Tsuchiya Y, Fukuda M, Niiro H, Hirota T. A Case Report of Drug Interactions Between Nirmatrelvir/Ritonavir and Tacrolimus in a Patient With Systemic Lupus Erythematosus. Cureus 2024; 16:e52506. [PMID: 38371142 PMCID: PMC10874239 DOI: 10.7759/cureus.52506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Nirmatrelvir/ritonavir is a treatment for COVID-19 consisting of nirmatrelvir, which has anti-SARS-CoV-2 activity, and ritonavir, a booster to maintain blood levels. Ritonavir is known to be a potent inhibitor of cytochrome P450 3A (CYP3A), and interactions with CYP3A-metabolized drugs, such as the immunosuppressant tacrolimus, can be problematic. Ritonavir's inhibition of CYP3A is irreversible due to covalent binding, and its inhibitory effects are expected to persist until replaced by new CYP3A. Here, we report a case where the combination of nirmatrelvir/ritonavir and tacrolimus resulted in toxic tacrolimus blood levels. A patient on tacrolimus for systemic lupus erythematosus (SLE) developed COVID-19 and was prescribed nirmatrelvir/ritonavir. After starting the combination of nirmatrelvir/ritonavir and tacrolimus, the patient's tacrolimus blood levels became abnormally high, leading to the discontinuation of these drugs due to symptoms of tacrolimus toxicity. Even after ritonavir blood levels had fallen below the detection limit, the decline in tacrolimus blood levels was delayed. The CYP3A inhibition of ritonavir persists even when its blood concentration decreases, emphasizing the need for careful consideration of concomitant medications before starting nirmatrelvir/ritonavir therapy. Adjustments or discontinuation may be necessary.
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Affiliation(s)
- Nanae Yamamoto
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
| | - Yuichi Tsuchiya
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
| | - Mio Fukuda
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
| | - Hiroaki Niiro
- Faculty of Medical Sciences, Department of Medical Education, Kyushu University, Fukuoka, JPN
| | - Takeshi Hirota
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
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Shiohira H, Arakaki S, Uehara W, Uehara H, Yamamoto K, Nakamura K. Nirmatrelvir/ritonavir-induced elevation of blood tacrolimus levels in a patient in the maintenance phase post liver transplantation. J Infect Chemother 2024; 30:77-80. [PMID: 37689137 DOI: 10.1016/j.jiac.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/11/2023]
Abstract
Nirmatrelvir is an orally administered anti-SARS-CoV-2 drug used in combination with ritonavir, the drug-metabolizing cytochrome P450 (CYP) 3A inhibitor, to evade metabolism and extend bioavailability. Meanwhile, the immunosuppressant tacrolimus is a CYP3A4/5 substrate, and CYP3A inhibition results in drug-drug interactions. Herein, we report the case of a coronavirus disease 19 (COVID-19) patient in the maintenance phase post liver transplantation, receiving tacrolimus treatment, with a marked increase of blood tacrolimus levels after the initiation of concomitant nirmatrelvir/ritonavir treatment. A 61-year-old Japanese woman underwent a living donor liver transplant for Caroli disease 25 years ago and received tacrolimus 2 mg/day for immunosuppressive treatment. Three days before the observed high tacrolimus blood concentration, she presented to our emergency department with a fever and was diagnosed with COVID-19. She was prescribed an adjusted dose of nirmatrelvir/ritonavir (150 mg/100 mg, twice daily) for 5 days as a high-risk case with immunosuppressive treatment and reduced renal function (estimated glomerular filtration rate, eGFR: 46.6 mL/min/1.73 m2). At the return visit on day 1, blood tacrolimus level was >60 ng/mL on trough sampling, above the upper limit of measurement, with nausea and vomiting as side effects. Tacrolimus treatment was discontinued on the same day. Drug-drug interactions resulting from CYP3A inhibition by nirmatrelvir/ritonavir were deemed responsible for elevated blood tacrolimus levels. Therefore, in liver transplant recipients, tacrolimus dose reduction or discontinuation is required during COVID-19 treatment with nirmatrelvir/ritonavir.
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Affiliation(s)
- Hideo Shiohira
- Department of Pharmacy, University of the Ryukyus Hospital, Japan
| | - Shingo Arakaki
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine (First Department of Internal Medicine), University of the Ryukyus, Japan
| | - Wataru Uehara
- Department of Pharmacy, University of the Ryukyus Hospital, Japan
| | - Hitoshi Uehara
- Department of Pharmacy, University of the Ryukyus Hospital, Japan
| | - Kazuko Yamamoto
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine (First Department of Internal Medicine), University of the Ryukyus, Japan
| | - Katsunori Nakamura
- Department of Pharmacy, University of the Ryukyus Hospital, Japan; Department of Pharmacotherapeutics, Graduate School of Medicine, University of the Ryukyus, Japan.
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Wanas H, Kamel MH, William EA, Fayad T, Abdelfattah ME, Elbadawy HM, Mikhael ES. The impact of CYP3A4 and CYP3A5 genetic variations on tacrolimus treatment of living-donor Egyptian kidney transplanted patients. J Clin Lab Anal 2023; 37:e24969. [PMID: 37789683 PMCID: PMC10681408 DOI: 10.1002/jcla.24969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/21/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Tacrolimus (TAC) is the mainstay of immunosuppressive regimen for kidney transplantations. Its clinical use is complex due to high inter-individual variations which can be partially attributed to genetic variations at the metabolizing enzymes CYP3A4 and CYP3A5. Two single nucleotide polymorphisms (SNPs), CYP3A4*22 and CYP3A5*3, have been reported as important causes of differences in pharmacokinetics that can affect efficacy and/or toxicity of TAC. OBJECTIVE Investigating the effect of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration in Egyptian renal recipients. METHODS Overall, 72 Egyptian kidney transplant recipients were genotyped for CYP3A4*22 G>A and CYP3A5*3 T>C. According to the functional defect associated with CYP3A variants, patients were clustered into: poor (PM) and non-poor metabolizers (Non-PM). The impact on dose adjusted through TAC concentrations (C0) and daily doses at different time points after transplantation was evaluated. RESULTS Cyp3A4*1/*22 and PM groups require significantly lower dose of TAC (mg/kg) at different time points with significantly higher concentration/dose (C0/D) ratio at day 10 in comparison to Cyp3A4*1/*1 and Non-PM groups respectively. However, CyP3A5*3 heterozygous individuals did not show any significant difference in comparison to CyP3A5*1/*3 individuals. By comparing between PM and Non-PM, the PM group had a significantly lower rate of recipients not reaching target C0 at day 14. CONCLUSION This is the first study on Egyptian population to investigate the impact of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration. This study and future multicenter studies can contribute to the individualization of TAC dosing in Egyptian patients.
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Affiliation(s)
- Hanaa Wanas
- Medical Pharmacology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
- Pharmacology and Toxicology Department, Faculty of PharmacyTaibah UniversityMadinahSaudi Arabia
| | - Mai Hamed Kamel
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | - Emad Adel William
- National Research Centre, Medical Research and Clinical Studies InstituteCairoEgypt
| | - Tarek Fayad
- Internal Medicine DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | | | | | - Emily Samir Mikhael
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
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Mizuno K, Capparelli EV, Fukuda T, Dong M, Adamson PC, Blumer JL, Cnaan A, Clark PO, Reed MD, Shinnar S, Vinks AA, Glauser TA. Model-Informed Precision Dosing Guidance of Ethosuximide Developed from a Randomized Controlled Clinical Trial of Childhood Absence Epilepsy. Clin Pharmacol Ther 2023; 114:459-469. [PMID: 37316457 DOI: 10.1002/cpt.2965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
Ethosuximide was identified as the optimal option for new-onset childhood absence epilepsy (CAE) in a randomized, two-phase dose escalation comparative effectiveness trial of ethosuximide, lamotrigine, and valproic acid. However, 47% of ethosuximide initial monotherapy participants experienced short-term treatment failure. This study aimed to characterize the initial monotherapy ethosuximide exposure-response relationship and to propose model-informed precision dosing guidance. Dose titration occurred over a 16-20-week period until patients experienced seizure freedom or intolerable side effects. Subjects with initial monotherapy failure were randomized to one of the other two medications and dose escalation was repeated. A population pharmacokinetic model was created using plasma concentration data (n = 1,320), collected at 4-week intervals from 211 unique participants during both the initial and second monotherapy phases. A logistic regression analysis was performed on the initial monotherapy cohort (n = 103) with complete exposure-response data. Eighty-four participants achieved seizure freedom with a wide range of ethosuximide area under the curves (AUC) ranging from 420 to 2,420 μg·h/mL. AUC exposure estimates for achieving a 50% and 75% probability of seizure freedom were 1,027 and 1,489 μg·h/mL, respectively, whereas the corresponding cumulative frequency of intolerable adverse events was 11% and 16%. Monte Carlo Simulation indicated a daily dose of 40 and 55 mg/kg to achieve 50% and 75% probability of seizure freedom in the overall population, respectively. We identified the need for adjusted mg/kg dosing in different body weight cohorts. This ethosuximide proposed model-informed precision dosing guidance to achieve seizure freedom carries promise to optimize initial monotherapy success for patients with CAE.
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Affiliation(s)
- Kana Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Edmund V Capparelli
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Peter C Adamson
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffery L Blumer
- Rainbow Clinical Research Center, Rainbow Babies and Children's Hospital, and Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Avital Cnaan
- Children's National Health System, Washington, DC, USA
| | - Peggy O Clark
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael D Reed
- Rainbow Clinical Research Center, Rainbow Babies and Children's Hospital, and Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Shlomo Shinnar
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tracy A Glauser
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Chen P, Dai R, She Y, Fu Q, Huang M, Chen X, Wang C. Prediction of tacrolimus and Wuzhi tablet pharmacokinetic interaction magnitude in renal transplant recipients. Clin Transplant 2022; 36:e14807. [PMID: 36057787 DOI: 10.1111/ctr.14807] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 12/27/2022]
Abstract
AIM Wuzhi tablets are a dose-sparing agent for tacrolimus (TAC) in China and increase the bioavailability of TAC. The current study aimed to evaluate the pharmacokinetic interaction magnitude of Wuzhi and TAC and explore the potential determinants of this interaction. METHODS This study performed a retrospective, self-controlled study of 138 renal transplant recipients who were co-administered TAC and Wuzhi. The trough concentration (C0) of TAC at baseline and 3, 7, 14 and 21 days after Wuzhi co-therapy initiation was measured, and the CYP3A5 polymorphism was genotyped. The corresponding clinical factors were recorded. The ratio of dose-adjusted C0 (C0/D) post- and pre-combination therapy (ΔC0/D) indicates the interaction magnitude. Univariate and multivariate analyses were used to identify determinants and establish the prediction model. RESULTS ΔC0/D reached a steady state within 14 days. The geometrical mean ΔC0/D was 2.91 (range 1.02-9.49, IQR 2.13-3.80). ΔC0/D was blunted in CYP3A5 expressers (estimated effect: -39.8%, P = .001) and affected by hematocrit (Hct) (+24.0% per 10% increase, P = .005) and baseline C0/D (-31.9% per 1 ng·ml-1 ·mg-1 increase, P < .001). The prediction model was ΔC0/D = .319baseline C0/D × 1.398CYP3A5 (expressers = 0/non-expressers = 1) × 1.024Hct × 1.744, and it explained 28.1% of the variability. CONCLUSION Our study is the first attempt to date to give an assessment of the magnitude of pharmacokinetic interaction between TAC and Wuzhi in a cohort of renal transplant recipients, and CYP3A5 genotypes, baseline C0/D and Hct were identified as determinants of this interaction.
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Affiliation(s)
- Pan Chen
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Rui Dai
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Youjun She
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Huang
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Changxi Wang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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De Gregori S, De Silvestri A, Cattadori B, Rapagnani A, Albertini R, Novello E, Concardi M, Arbustini E, Pellegrini C. Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy in Heart Transplantation: New Strategies and Preliminary Results in Endomyocardial Biopsies. Pharmaceutics 2022; 14:pharmaceutics14061247. [PMID: 35745819 PMCID: PMC9229567 DOI: 10.3390/pharmaceutics14061247] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/24/2022] [Accepted: 06/10/2022] [Indexed: 11/16/2022] Open
Abstract
Tacrolimus (TAC) is an immunosuppressant drug approved both in the US and in the EU, widely used for the prophylaxis of organ rejection after transplantation. This is a critical dose drug: low levels in whole blood can lead to low exposure and a high risk of acute rejection, whereas overexposure puts patients at risk for toxicity and infection. Both situations can occur at whole-blood concentrations considered to be within the narrow TAC therapeutic range. We assumed a poor correlation between TAC trough concentrations in whole blood and the incidence of acute rejection; therefore, we propose to study TAC concentrations in endomyocardial biopsies (EMBs). We analyzed 70 EMBs from 18 transplant recipients at five scheduled follow-up visits during the first year post-transplant when closer TAC monitoring is mandatory. We observed five episodes of acute rejection (grade 2R) in three patients (2 episodes at 0.5 months, 2 at 3 months, and 1 at 12 months), when TAC concentrations in EMBs were low (63; 62; 59; 31; 44 pg/mg, respectively), whereas concentrations in whole blood were correct. Our results are preliminary and further studies are needed to confirm the importance of this new strategy to prevent acute rejection episodes.
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Affiliation(s)
- Simona De Gregori
- U.O.C Laboratorio Analisi Chimico Cliniche, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (R.A.); (E.N.)
- Correspondence: ; Tel.: +39-0382-503647
| | - Annalisa De Silvestri
- U.O.S Epidemiologia Clinica e Biostatistica, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Barbara Cattadori
- U.O.C. di Cardiochirurgia, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Andrea Rapagnani
- Unità di Chirurgia Cardiaca, Dipartimento di Scienze Clinico Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia, 27100 Pavia, Italy;
| | - Riccardo Albertini
- U.O.C Laboratorio Analisi Chimico Cliniche, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (R.A.); (E.N.)
| | - Elisa Novello
- U.O.C Laboratorio Analisi Chimico Cliniche, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (R.A.); (E.N.)
| | - Monica Concardi
- Centro Malattie Genetiche Cardiovascolari, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.C.); (E.A.)
| | - Eloisa Arbustini
- Centro Malattie Genetiche Cardiovascolari, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.C.); (E.A.)
| | - Carlo Pellegrini
- Unità di Chirurgia Cardiaca, Dipartimento di Scienze Clinico Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia—U.O.C. di Cardiochirurgia, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
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Kou K, Sun X, Li M, Li T, Hu Y, Li S, Lv G. Beneficial effects of Wuzhi Capsule on tacrolimus blood concentrations in liver transplant patients with different donor-recipient CYP3A5 genotypes. J Clin Pharm Ther 2021; 47:200-210. [PMID: 34708436 DOI: 10.1111/jcpt.13533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/02/2021] [Accepted: 09/14/2021] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tacrolimus (Tac) is an immunosuppressant that is widely used to prevent allograft rejection in patients after liver transplantation. Its metabolism mainly depends on the cytochrome P450 3A5 (CYP3A5), which has genetic polymorphisms. Recently, a Chinese herbal medicine known as Wuzhi Capsule (WZC) was shown to increase Tac blood concentrations by inhibiting the activity of CYP3A in animal studies in rats. To date, it remains unexplored whether WZC can be efficiently used to enhance the blood concentration of Tac in liver transplant patients with different donor-recipient CYP3A5 genotypes. METHODS A total of 185 liver transplant patients were enrolled and two-way ANOVA was carried out, then they were divided into four groups according to the combinations of donor-recipient CYP3A5 phenotypes. WZC was given to patients when the dose of Tac was ≥4 mg, and the dose-adjusted C0 (C0 /D) of Tac measured twice in succession was ≤1 ng/ml/mg. The blood trough concentration of Tac (C0 ), C0 /D, and dose- and body weight-adjusted C0 (C0 /D/W) was analysed on days 7 and 14 after liver transplantation. RESULTS The genotypes of donor and recipient or WZC had significant effects on C0, C0/D and C0/D/W. There were significant differences in the Tac blood concentrations between the groups. The recipient expression (*1)/donor expression (*1) (R+/D+) group had the lowest C0 , C0 /D and C0 /D/W among the four groups. Furthermore, a larger proportion of patients in the CYP3A5 expression groups required Tac dose adjustment to achieve a therapeutic effect and were given Tac with WZC. Notably, the use of WZC significantly increased the blood concentrations of Tac in the CYP3A5 expression groups and greater increases in the C0 /D and C0 /D/W were significantly associated with higher doses of WZC in the CYP3A5 expression groups. What is more, WZC reduced the hospitalization cost of patients to a certain extent. WHAT IS NEW AND CONCLUSION WZC significantly increased the C0 , C0 /D and C0 /D/W in the CYP3A5 expression groups and reduced the hospitalization expenses of patients to a certain extent. What is more, greater increases in the C0 /D and C0 /D/W were significantly associated with higher doses of WZC.
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Affiliation(s)
- Kai Kou
- Department of Hepatobiliary surgery, Jilin University First Hospital, Changchun, China
| | - Xiaodong Sun
- Department of Hepatobiliary surgery, Jilin University First Hospital, Changchun, China
| | - Mingqian Li
- Department of Hepatobiliary surgery, Jilin University First Hospital, Changchun, China
| | - Ting Li
- Department of Hepatobiliary surgery, Jilin University First Hospital, Changchun, China
| | - Yuelei Hu
- Department of Hepatobiliary surgery, Jilin University First Hospital, Changchun, China
| | - Shuxuan Li
- Department of Hepatobiliary surgery, Jilin University First Hospital, Changchun, China
| | - Guoyue Lv
- Department of Hepatobiliary surgery, Jilin University First Hospital, Changchun, China
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[The effect of CYP3A5 gene polymorphism on tacrolimus concentration and adverse events in patients undergoing allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:828-833. [PMID: 34788922 PMCID: PMC8607024 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
目的 探讨在异基因造血干细胞移植(allo-HSCT)患者中,CYP3A5基因多态性与他克莫司血药浓度及急性移植物抗宿主病(GVHD)间的关系。 方法 回顾性分析2019年7月至2020年2月在中国医学科学院血液病医院接受allo-HSCT的35例中国成人患者。移植前采集骨髓进行CYP3A5基因分型。应用静脉输注他克莫司、短疗程甲氨蝶呤(MTX)±吗替麦考酚酯进行GVHD预防。在他克莫司用药第2天或第3天监测初始血药浓度,随后每周监测2~3次。根据目标血药浓度(10~15 ng/ml)调整药物剂量。 结果 16例携带CYP3A5*3/*3基因的allo-HSCT患者的初始他克莫司血药浓度(9.82 ng/ml对8.53 ng/ml)、初始血药浓度/剂量(C/D)比值(5.72 ng·ml−1·mg−1对4.26 ng·ml−1·mg−1)、allo-HSCT后第一和第二周C/D比值中位数(5.29 ng·ml−1·mg−1对4.61 ng·ml−1·mg−1,5.65 ng·ml−1·mg−1对4.56 ng·ml−1·mg−1)均明显高于19例至少携带一个CYP3A5*1等位基因的患者(P值分别为0.028、0.001、0.037、0.045)。至少携带一个CYP3A5*1等位基因的患者,allo-HSCT后Ⅲ~Ⅳ级急性GVHD的发生率有高于携带CYP3A5*3/*3基因患者的趋势[(26.3±10.1)%对(6.2±6.1)%,P=0.187]。 结论 CYP3A5基因型导向给药可能有助于allo-HSCT后更快地达到他克莫司目标血药浓度,减少严重急性GVHD的发生,改善移植疗效。
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11
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Extrapolation of physiologically based pharmacokinetic model for tacrolimus from renal to liver transplant patients. Drug Metab Pharmacokinet 2021; 42:100423. [PMID: 34896748 DOI: 10.1016/j.dmpk.2021.100423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/18/2021] [Accepted: 09/27/2021] [Indexed: 11/22/2022]
Abstract
Physiologically based pharmacokinetic (PBPK) modeling is useful for evaluating differences in drug exposure among special populations, but it has not yet been employed to evaluate the absorption process of tacrolimus. In this study, we developed a minimal PBPK model with a compartmental absorption and transit model for renal transplant patients using available data in the literature and clinical data from our hospital. The effective permeability value of tacrolimus absorption and parameters for the single adjusting compartment were optimized via sensitivity analyses, generating a PBPK model of tacrolimus for renal transplant patients with good predictability. Next, we extrapolated the pharmacokinetics of tacrolimus for liver transplant patients by changing the population demographic parameters of the model. When the physiological parameters of a population with normal liver function were changed to those of a population with impaired hepatic function (Child-Pugh class A) in the constructed renal transplant PBPK model, the predicted tacrolimus concentrations were consistent with the observed concentrations in liver transplant patients. In conclusion, the constructed tacrolimus PBPK model for renal transplant patients could predict the pharmacokinetics in liver transplant patients by slightly reducing the hepatic function, even at three weeks post-transplantation.
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de Loor H, Vanhove T, Annaert P, Lescrinier E, Kuypers D. Determination of tacrolimus, three mono-demethylated metabolites and a M1 tautomer in human whole blood by liquid chromatography - tandem mass spectrometry. J Pharm Biomed Anal 2021; 205:114296. [PMID: 34392130 DOI: 10.1016/j.jpba.2021.114296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/20/2021] [Accepted: 07/30/2021] [Indexed: 12/22/2022]
Abstract
The immunosuppressant tacrolimus is the primary drug used in kidney transplantation to prevent organ rejection. A sensitive ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method was developed to measure tacrolimus and its three known mono-demethylated metabolites 13-O-desmethyl tacrolimus (M1), 31-O-desmethyl tacrolimus (M2), 15-O-desmethyl tacrolimus (M3). By generating the metabolites to use as standards after incubation of tacrolimus with rat liver microsomes, we discovered multiple M1 peaks which we identified as two tautomers of M1. The M1 tautomer II was also successfully validated in this method. The separation and purification of the metabolites and tautomers were performed by semi-preparative liquid chromatography with UV-detection, while confirmation was done by UPLC-MS/MS and Nuclear Magnetic Resonance. For quantification an easy sample preparation was performed with zinc sulfate and acetonitrile as cell lyses and precipitation. Detection was performed in positive electrospray ionization. By better characterization of the metabolites and the tautomers, we could possibly explain insight into the clinical condition and thus adjust the immunosuppressant therapy individually per patient. Calibration curves were linear for all compounds. Precision was assessed according to the NCCLS EP5-T guideline, being below 15 % and mean recoveries were between 93 and 110 % for tacrolimus, its three metabolites and the M1 tautomer II. The validated method was successfully applied in a cohort of 20 patients after kidney transplantation.
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Affiliation(s)
- Henriette de Loor
- KU Leuven - University of Leuven, Department of Microbiology and Immunology, Nephrology and Renal Transplantation Research Group, B-3000, Leuven, Belgium
| | - Thomas Vanhove
- KU Leuven - University of Leuven, Department of Microbiology and Immunology, Nephrology and Renal Transplantation Research Group, B-3000, Leuven, Belgium; University Hospitals Leuven, Department of Nephrology and Renal Transplantation, B-3000, Leuven, Belgium
| | - Pieter Annaert
- KU Leuven - University of Leuven, Department of Pharmaceutical and Pharmacological Sciences, Drug Delivery and Disposition, B-3000, Leuven, Belgium
| | - Eveline Lescrinier
- KU Leuven - University of Leuven, Department of Pharmaceutical and Pharmacological Sciences, Medicinal Chemistry, B-3000, Leuven, Belgium
| | - Dirk Kuypers
- University Hospitals Leuven, Department of Nephrology and Renal Transplantation, B-3000, Leuven, Belgium.
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13
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Chen X, Wang DD, Xu H, Li ZP. Initial dose recommendation for sirolimus in paediatric kaposiform haemangioendothelioma patients based on population pharmacokinetics and pharmacogenomics. J Int Med Res 2021; 48:300060520947627. [PMID: 32815764 PMCID: PMC7444137 DOI: 10.1177/0300060520947627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Sirolimus has been used to treat paediatric kaposiform haemangioendothelioma patients. However, there is considerable pharmacokinetic variability among individuals, and it is difficult to develop an initial dosing regimen. The goal of the present study is to recommend an initial sirolimus dose in paediatric kaposiform haemangioendothelioma patients based on population pharmacokinetics and pharmacogenomics. Methods This was a retrospective clinical study. A population pharmacokinetics model was established and population characteristics, laboratory test results, drug combinations, and pharmacogenomics were considered as potential covariates. The Monte Carlo method was used to simulate the optimal initial dosage. Results The final covariates that affect sirolimus clearance include weight and the CYP3A5 genotype. The initial dosage of sirolimus for individuals with CYP3A5*3/*3 was 0.20 mg/kg split into two doses for 5 to 60 kg body weight. For individuals with CYP3A5*1, the initial dose was 0.23 mg/kg split into two doses for 5 to 30 kg body weight and 0.20 mg/kg split into two doses for 30 to 60 kg body weight. Conclusion The recommendation for the initial sirolimus dose in paediatric kaposiform haemangioendothelioma patients was based on population pharmacokinetics and pharmacogenomics. This study may provide practical value for sirolimus clinical use in paediatric kaposiform haemangioendothelioma patients.
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Affiliation(s)
- Xiao Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Dong-Dong Wang
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhi-Ping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
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14
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Significance of Ethnic Factors in Immunosuppressive Therapy Management After Organ Transplantation. Ther Drug Monit 2021; 42:369-380. [PMID: 32091469 DOI: 10.1097/ftd.0000000000000748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clinical outcomes after organ transplantation have greatly improved in the past 2 decades with the discovery and development of immunosuppressive drugs such as calcineurin inhibitors, antiproliferative agents, and mammalian target of rapamycin inhibitors. However, individualized dosage regimens have not yet been fully established for these drugs except for therapeutic drug monitoring-based dosage modification because of extensive interindividual variations in immunosuppressive drug pharmacokinetics. The variations in immunosuppressive drug pharmacokinetics are attributed to interindividual variations in the functional activity of cytochrome P450 enzymes, UDP-glucuronosyltransferases, and ATP-binding cassette subfamily B member 1 (known as P-glycoprotein or multidrug resistance 1) in the liver and small intestine. Some genetic variations have been found to be involved to at least some degree in pharmacokinetic variations in post-transplant immunosuppressive therapy. It is well known that the frequencies and effect size of minor alleles vary greatly between different races. Thus, ethnic considerations might provide useful information for optimizing individualized immunosuppressive therapy after organ transplantation. Here, we review ethnic factors affecting the pharmacokinetics of immunosuppressive drugs requiring therapeutic drug monitoring, including tacrolimus, cyclosporine, mycophenolate mofetil, sirolimus, and everolimus.
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Willuweit K, Frey A, Hörster A, Saner F, Herzer K. Real-World Administration of Once-Daily MeltDose ® Prolonged-Release Tacrolimus (LCPT) Allows for Dose Reduction of Tacrolimus and Stabilizes Graft Function Following Liver Transplantation. J Clin Med 2020; 10:jcm10010124. [PMID: 33396492 PMCID: PMC7795274 DOI: 10.3390/jcm10010124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 01/16/2023] Open
Abstract
The calcineurin inhibitor tacrolimus is included in most immunosuppressive protocols after liver transplantation. This retrospective, observational 24-month study investigated the tolerability of once-daily MeltDose® prolonged-release tacrolimus (LCPT) after switching from twice-daily immediate-release tacrolimus (IR-Tac) in a real-world cohort of 150 patients with previous liver transplantation. No graft rejection or new safety signals were observed. Only 7.3% of patients discontinued LCPT due to side effects. In the overall patient population, median liver transaminases, total cholesterol, triglycerides, glucose, and HbA1c remained constant after switching to LCPT. Total cholesterol significantly decreased (p ≤ 0.002) in patients with initially elevated levels (>200 mg/dL). A total of 71.8% of 96 patients maintained a glomerular filtration rate > 60 mL/min/1.73 m2 throughout the study, while 44.7% of patients were classified as fast metabolizers and 55.3% as slow metabolizers. Median daily tacrolimus dose could be reduced by 50% in fast metabolizers and by 30% in slow metabolizers, while trough levels were maintained in the target range (4–6 ng/mL). In conclusion, our observational study confirmed previous evidence of good overall tolerability and a favorable outcome for the patients after switching from IR-Tac to LCPT after liver transplantation.
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Affiliation(s)
- Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
- Correspondence: (K.W.); (K.H.); Tel.: +49-2641-860 (K.H.)
| | - Alexandra Frey
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
| | - Anne Hörster
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany;
| | - Kerstin Herzer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
- Knappschaftsklinik Bad Neuenahr, Georg-Kreuzberg-Straße 2-6, 53474 Bad Neuenahr, Germany
- Correspondence: (K.W.); (K.H.); Tel.: +49-2641-860 (K.H.)
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Csikány N, Kiss Á, Déri M, Fekete F, Minus A, Tóth K, Temesvári M, Sárváry E, Bihari L, Gerlei Z, Kóbori L, Monostory K. Clinical significance of personalized tacrolimus dosing by adjusting to donor CYP3A-status in liver transplant recipients. Br J Clin Pharmacol 2020; 87:1790-1800. [PMID: 32986876 DOI: 10.1111/bcp.14566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/02/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Donor's CYP3A-status (CYP3A5 genotype and CYP3A4 expression) can provide prognostic information regarding tacrolimus-metabolizing capacity of the liver graft and initial tacrolimus dosing for therapeutic blood concentrations in liver transplants. The present work prospectively investigated whether CYP3A-status guided tacrolimus therapy has any potential clinical benefit for recipients in the early postoperative period. METHODS The contribution of preliminary assaying of donor CYP3A-status to the optimization of initial tacrolimus therapy and to the reduction of adverse events (acute rejection, infection, nephrotoxicity) was investigated in 112 liver transplant recipients (CYPtest group) comparing to 101 control patients on tacrolimus concentration guided therapy. RESULTS The time for achieving therapeutic tacrolimus concentration was significantly reduced, confirming potential benefit of initial tacrolimus therapy adjusted to donor's CYP3A-status over classical clinical practice of tacrolimus concentration guided treatment (4 vs 8 days, P < 0.0001). Acute rejection episodes (3.6 vs 23.8%, P < 0.0001) and tacrolimus induced nephrotoxicity (8 vs 27%, P = 0.0004) were less frequent in CYPtest group than in control patients, whereas occurrence of infectious disease was not influenced by tacrolimus dosing strategy (3.6 vs 5.9% in CYPtest and control groups, P > 0.05). Acute rejection was often accompanied with tacrolimus blood concentrations lower than 10 ng mL-1 (20/24 of control and 2/4 of CYPtest patients), while nephrotoxicity was associated with high tacrolimus concentrations (>20 ng mL-1 ) in the first week after transplantation (13/27 of control and 2/9 of CYPtest patients). CONCLUSION CYP3A-status guided therapy significantly improved the risk of misdosing induced early adverse effects (acute rejection, nephrotoxicity).
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Affiliation(s)
- Nóra Csikány
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Ádám Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Máté Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Ferenc Fekete
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Annamária Minus
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Manna Temesvári
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Bihari
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Zsuzsa Gerlei
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
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The Advantages of Polymeric Hydrogels in Calcineurin Inhibitor Delivery. Processes (Basel) 2020. [DOI: 10.3390/pr8111331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In recent years, polymeric hydrogels (PolyHy) have been extensively explored for their applications in biomedicine as biosensors, in tissue engineering, diagnostic processes, and drug release. The physical and chemical properties of PolyHy indicate their potential use in regulating drug delivery. Calcineurin inhibitors, particularly cyclosporine (CsA) and tacrolimus (TAC), are two important immunosuppressor drugs prescribed upon solid organ transplants. Although these drugs have been used since the 1970s to significantly increase the survival of transplanted organs, there are concerns regarding their undesirable side effects, primarily due to their highly variable concentrations. In fact, calcineurin inhibitors lead to acute and chronic toxicities that primarily cause adverse effects such as hypertension and nephrotoxicity. It is suggested from the evidence that the encapsulation of calcineurin inhibitors into PolyHy based on polysaccharides, specifically alginate (Alg), offers effective drug delivery with a stable immunosuppressive response at the in vitro and in vivo levels. This not only may reduce the adverse effects but also would improve the adherence of the patients by the effective preservation of drug concentrations in the therapeutic ranges.
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Wang P, Zhang Q, Tian X, Yang J, Zhang X. Tacrolimus Starting Dose Prediction Based on Genetic Polymorphisms and Clinical Factors in Chinese Renal Transplant Recipients. Genet Test Mol Biomarkers 2020; 24:665-673. [PMID: 32985896 DOI: 10.1089/gtmb.2020.0077] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aims: Tacrolimus has extensive pharmacokinetic variability among patients and a narrow therapeutic window. The U.S. Clinical Pharmacogenetics Implementation Consortium recommends a starting dose for tacrolimus of 0.15-0.3 mg/kg/day, which is much higher compared with 0.05-0.15 mg/kg/day used in China. The purpose of this study was to investigate the influence of clinical factors and single nucleotide polymorphisms (SNPs) on tacrolimus concentrations in Chinese renal transplant recipients. Methods: This study enrolled 406 tacrolimus-treated patients. After renal transplantation, the first tacrolimus trough concentration and corresponding clinical information were collected from all patients. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry was used to genotype 15 SNPs. The relationship between the genetic and clinical factors and dose-adjusted tacrolimus trough concentration was examined. The tacrolimus starting dose was predicted using a classification and regression tree analysis. Results: Examination of the 15 SNPs and several clinical factors identified the CYP3A5 genotype (p = 5.6 × 10-11) and hemoglobin (p = 8.4 × 10-10) as the most significant determinants of tacrolimus C0/D. Accordingly, a concise tacrolimus recommendation dosage model, a classification scheme, and a regression tree were developed. Conclusion: A new classification and regression tree model was developed for establishing the starting dose of tacrolimus based on the CYP3A5 genotype and hemoglobin values. This result may help clinicians prescribe an appropriate initial tacrolimus dose. ClinicalTrials.gov ID: 2020-KY-147.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xueke Tian
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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Chen X, Wang DD, Li ZP. Analysis of time course and dose effect of tacrolimus on proteinuria in lupus nephritis patients. J Clin Pharm Ther 2020; 46:106-113. [PMID: 32974902 DOI: 10.1111/jcpt.13260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/11/2020] [Accepted: 08/17/2020] [Indexed: 12/21/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Tacrolimus is used to treat patients with lupus nephritis; however, its time course and dose effect on proteinuria in lupus nephritis patients remain unknown. The purpose of this study was to determine the time course and dose effect of tacrolimus on proteinuria in lupus nephritis patients via model-based meta-analysis (MBMA). METHODS PubMed, Web of Science, Cochrane Library and ClinicalTrials.gov databases were systematically searched for information on the efficacy of tacrolimus against proteinuria in lupus nephritis patients. Useful data were extracted to build a model for the population studied using a non-linear mixed-effect model (NONMEM). This model was applied to simulate time course of tacrolimus on proteinuria using Monte Carlo simulations. RESULTS Ten clinical studies that recruited 222 patients with lupus nephritis were included. Based on various diagnostic plots, we found that the established model described the observed data reasonably well. In addition, the typical Emax and ET50 of tacrolimus for 24-hour proteinuria in lupus nephritis patients were -5.88 g and 0.37 months, respectively. The baseline value of 24-hour proteinuria affected Emax . No significant dose-response relationship was observed in the range of tacrolimus concentration used in the present study (3-10 ng/mL), indicating that the effect of tacrolimus on proteinuria depends on effective concentration range and not the dose. However, the time course relationship was obvious; the efficacy of tacrolimus increased over time, reaching a plateau (80% Emax ) at approximately 1.48 months from the beginning of treatment. WHAT IS NEW AND CONCLUSION When the concentration range of tacrolimus is maintained at 3-10 ng/mL, at least 1.48 months of treatment is required to achieve a better outcome with regard to proteinuria in lupus nephritis patients.
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Affiliation(s)
- Xiao Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Dong-Dong Wang
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Zhi-Ping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
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CYP3A5 Genotype as a Potential Pharmacodynamic Biomarker for Tacrolimus Therapy in Ulcerative Colitis in Japanese Patients. Int J Mol Sci 2020; 21:ijms21124347. [PMID: 32570960 PMCID: PMC7352351 DOI: 10.3390/ijms21124347] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 12/14/2022] Open
Abstract
Tacrolimus has been used to induce remission in patients with steroid-refractory ulcerative colitis. It poses a problem of large individual differences in dosage necessary to attain target blood concentration and, often, this leads to drug inefficacy. We examined the difference in mRNA expression levels of ATP binding cassette transporter B1 (ABCB1) between inflamed and non-inflamed tissues, and the influence of CYP3A5 genotype on tacrolimus therapy. The mRNA expression of CYP3A4 in colonic mucosa and that of cytochrome p450 3A5 (CYP3A5) and ABCB1 in inflamed and non-inflamed areas were examined in 14 subjects. The mRNA expression levels of CYP3A5 were higher than that of CYP3A4. The mRNA expression of ABCB1 was lower in the inflamed than in the non-inflamed mucosa, despite that of CYP3A5 mRNA level being not significantly changed. Hence, the deterioration of the disease is related to the reduction of the barrier in the inflamed mucosa. The relationship between CYP3A5 genotype and blood concentration, dose, and concentration/dose (C/D) ratio of tacrolimus in 15 subjects was studied. The tacrolimus dose to maintain equivalent blood concentrations was lower in CYP3A5*3/*3 than in CYP3A5*1 carriers, and the C/D ratio was significantly higher in the latter. Thus, CYP3A5 polymorphism information played a role in determining the initial dose of tacrolimus. Furthermore, since the effect of tacrolimus appears earlier in CYP3A5*3/*3 than in CYP3A5*1/*1 and *1/*3, it seems necessary to change the evaluation time of therapeutic effect by CYP3A5 genotype. Additionally, the relationship between CYP3A5 genotype and C/D ratio of tacrolimus in colonic mucosa was investigated in 10 subjects. Tacrolimus concentration in the mucosa was two-fold higher in CYP3A5*3/*3 than in CYP3A5*1 carriers, although no significant difference in tacrolimus-blood levels was observed. Therefore, the local concentration of tacrolimus affected by CYP3A5 polymorphism might be related to its therapeutic effect.
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Chen X, Wang DD, Xu H, Li ZP. Initial dosage optimization of tacrolimus in Chinese pediatric patients undergoing kidney transplantation based on population pharmacokinetics and pharmacogenetics. Expert Rev Clin Pharmacol 2020; 13:553-561. [PMID: 32452705 DOI: 10.1080/17512433.2020.1767592] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Xiao Chen
- Department of Pharmacy, Children’s Hospital of Fudan University, Shanghai, China
| | - Dong-Dong Wang
- Department of Pharmacy, Children’s Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children’s Hospital of Fudan University, Shanghai, China
| | - Zhi-Ping Li
- Department of Pharmacy, Children’s Hospital of Fudan University, Shanghai, China
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Huang L, Wang J, Yang J, Zhang H, Ni Y, Zhu Z, Wang H, Gao P, Wu Y, Mao J, Fang L. Impact of CYP3A4/5 and ABCB1 polymorphisms on tacrolimus exposure and response in pediatric primary nephrotic syndrome. Pharmacogenomics 2020; 20:1071-1083. [PMID: 31588879 DOI: 10.2217/pgs-2019-0090] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aim: To evaluate the impact of CYP3A4*1G, CYP3A5*3 and ABCB1-C3435T polymorphisms on tacrolimus concentrations, efficacy and tolerance in pediatric primary nephrotic syndrome. Methods: Dose-adjusted concentrations (C0/D), daily dose, frequency and time to relapse, cumulative remission days, and adverse reactions in 65 Chinese patients with various genotypes were retrospectively collected and compared. Results: C0/D increased in CYP3A4*1/*1, CYP3A5*3/*3 and CYP3A4*1/*1-3A5*3/*3 diplotype carriers by 38.4, 69.7 and 40.9% compared with CYP3A4*1/*1G, CYP3A5*1/*3 and noncarriers, respectively. Recurrence risks were decreased in CYP3A4*1/*1 (0.43 of hazard ratio to *1/*1G) and CYP3A5*3/*3 carriers (0.43 of hazard ratio to *1/*3). None of polymorphisms was linked to adverse reactions. Conclusion: The genotypes of CYP3A4*1G and CYP3A5*3 rather than ABCB1-C3435T potentially predicted tacrolimus exposure and clinical response in pediatric primary nephrotic syndrome.
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Affiliation(s)
- Lingfei Huang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Junyan Wang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Jufei Yang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Huifen Zhang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Yinghua Ni
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Zhengyi Zhu
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Huijuan Wang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Peng Gao
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Yuanyuan Wu
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Jianhua Mao
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
| | - Luo Fang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, PR China
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Worsening of Kidney Transplant Function During 2-Year Follow-up Is Associated With the Genetic Variants of CYP3A4, MDR1, and UGT1A9. Transplant Proc 2020; 52:2363-2367. [PMID: 32222391 DOI: 10.1016/j.transproceed.2020.02.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/09/2020] [Accepted: 02/13/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Calcineurin inhibitors (CNIs), tacrolimus and cyclosporine, undergo pharmacokinetic processes. Enzymes and transport proteins found in various organs are involved. It is possible that genetic polymorphisms of these proteins influence CNIs pharmacokinetics and the generation of CNIs metabolites. CNIs may be nephrotoxic, and it is thought that some CNIs' metabolites may have a similar effect. The study was aimed at the assessment of the relationship between selected gene polymorphisms for enzymes and transport proteins and change of estimated glomerular filtration rate (eGFR) during a 2-year follow-up in kidney transplant (KTX) patients. METHODS The study involved 366 patients after KTX (160 women; 43.7%) receiving tacrolimus (62.57%) and cyclosporine (37.43%). The mean age was 50.1 years, and the median time after KTX was 60.5 months. The study protocol conformed with the Declaration of Helsinki. The percent of difference between eGFR at baseline and at 24 months (ΔeGFR) was calculated. We evaluated selected genetic polymorphisms of CYP3A4, CYP3A5, MDR1, UGT1A9, UGT2B7, UGT1A8, and MRP2. RESULTS In the tacrolimus group, there were no significant differences of ΔeGFR between groups distinguished based on analyzed genotypes. In the cyclosporine group, differences were found for CYP3A4∗22 C/C -12.3 (-26.8 to -1.8) versus C/T 13.2 (12.4 to 13.9), P = .034; MDR1 3435C>T C/T -18.2 (-31.5 to -5.7) versus C/C -1.8 (-17.1 to 6.9) vs T/T -8.1 (-18.4 to 12.4), P = .031; and UGT1A9 2152C>T C/C -9.0 (-25.5 to 2.8) versus C/T -26.8 (-31.9 to -24.1), P = .017. CONCLUSION The study results suggest that in KTX metabolic transformations and transport, especially of cyclosporine, dependence on the genetic variability of CYP3A4, UGT1A9, and MDR1 may contribute to kidney damage.
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Nakamura T, Fukuda M, Matsukane R, Suetsugu K, Harada N, Yoshizumi T, Egashira N, Mori M, Masuda S. Influence of POR*28 Polymorphisms on CYP3A5*3-Associated Variations in Tacrolimus Blood Levels at an Early Stage after Liver Transplantation. Int J Mol Sci 2020; 21:ijms21072287. [PMID: 32225074 PMCID: PMC7178010 DOI: 10.3390/ijms21072287] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 12/19/2022] Open
Abstract
It is well known that the CYP3A5*3 polymorphism is an important marker that correlates with the tacrolimus dose requirement after organ transplantation. Recently, it has been revealed that the POR*28 polymorphism affects the pharmacokinetics of tacrolimus in renal transplant patients. In this study, we examined whether POR*28 as well as CYP3A5*3 polymorphism in Japanese recipients and donors would be another biomarker for the variation of tacrolimus blood levels in the recipients during the first month after living-donor liver transplantation. We enrolled 65 patients treated with tacrolimus, who underwent liver transplantation between July 2016 and January 2019. Genomic DNA was extracted from whole-blood samples, and genotyping was performed to examine the presence of CYP3A5*3 and POR*28 polymorphisms in the recipients and donors. The CYP3A5*3/*3 genotype (defective CYP3A5) of the recipient (standard partial regression coefficient [median C/D ratio of CYP3A5 expressor vs. CYP3A5 non-expressor, p value]: Pod 1–7, β= −0.389 [1.76 vs. 2.73, p < 0.001]; Pod 8–14, β = −0.345 [2.03 vs. 2.83, p < 0.001]; Pod 15–21, β= −0.417 [1.75 vs. 2.94, p < 0.001]; Pod 22–28, β = −0.627 [1.55 vs. 2.90, p < 0.001]) rather than donor (Pod 1–7, β = n/a [1.88 vs. 2.76]; Pod 8–14, β = n/a [1.99 vs. 2.93]; Pod 15–21, β = −0.175 [1.91 vs. 2.94, p = 0.004]; Pod 22–28, β = n/a [1.61 vs. 2.67]) significantly contributed to the increase in the concentration/dose (C/D) ratio of tacrolimus for at least one month after surgery. We found that the tacrolimus C/D ratio significantly decreased from the third week after transplantation when the recipient carried both CYP3A5*1 (functional CYP3A5) and POR*28 (n = 19 [29.2%], median C/D ratio [inter quartile range] = 1.58 [1.39–2.17]), compared with that in the recipients carrying CYP3A5*1 and POR*1/*1 (n = 8 [12.3%], median C/D ratio [inter quartile range] = 2.23 [2.05–3.06]) (p < 0.001). In conclusion, to our knowledge, this is the first report suggesting that the POR*28 polymorphism is another biomarker for the tacrolimus oral dosage after liver transplantation in patients carrying CYP3A5*1 rather than CYP3A5*3/*3.
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Affiliation(s)
- Takahiro Nakamura
- Department of Clinical Pharmacology and Biopharmaceutics, The Pharmaceutical College, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Mio Fukuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.F.); (R.M.); (K.S.); (N.E.)
| | - Ryosuke Matsukane
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.F.); (R.M.); (K.S.); (N.E.)
| | - Kimitaka Suetsugu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.F.); (R.M.); (K.S.); (N.E.)
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (N.H.); (T.Y.); (M.M.)
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (N.H.); (T.Y.); (M.M.)
| | - Nobuaki Egashira
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.F.); (R.M.); (K.S.); (N.E.)
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (N.H.); (T.Y.); (M.M.)
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.F.); (R.M.); (K.S.); (N.E.)
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita 286-0124, Japan
- Correspondence: ; Tel.: +81-476-28-1401
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25
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Cai N, Zhang X, Zheng C, Zhu L, Zhu M, Cheng Z, Luo X. A novel random forest integrative approach based on endogenous CYP3A4 phenotype for predicting tacrolimus concentrations and dosages in Chinese renal transplant patients. J Clin Pharm Ther 2019; 45:318-323. [PMID: 31721244 DOI: 10.1111/jcpt.13074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/16/2019] [Accepted: 10/22/2019] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Personalized treatment with tacrolimus has remained a challenge. The present study aimed to evaluate the potential of an integrative approach to predict individual tacrolimus concentrations and dosages based on endogenous CYP3A4 phenotype, CYP3A5 genotype and clinical variables. METHODS A random forest (RF) algorithm which incorporated an endogenous CYP3A4 phenotype (assessed by urinary ratio of 6β-hydroxycortisol and 6β-hydroxycortisone to cortisol and cortisone), CYP3A5*3 genotype and other clinical determinants of tacrolimus disposition was performed in 182 medically stable renal transplant recipients. RESULTS AND DISCUSSION The results suggested that endogenous CYP3A4 phenotype was the most important determinant of tacrolimus concentrations and dose requirements. RF models provided high goodness of fit (R2 ) with .92 and .95 for the prediction of tacrolimus trough concentrations and dosages, respectively, as well as high predictability (Q2 ) with 0.63 and 0.70, respectively. Significant correlations existed between experimental and predictive data. WHAT IS NEW AND CONCLUSION In summary, endogenous CYP3A4 phenotype is a critical biomarker for the determination of tacrolimus disposition. This predictive RF approach based on CYP3A4 biomarker with the combination of CYP3A5*3 genotype and other clinical variables can be used for predicting tacrolimus concentrations and dosages, which may serve as a useful tool in individualized tacrolimus dosing.
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Affiliation(s)
- Ningfang Cai
- Department of Pharmacy, Xiamen Children's Hospital, Xiamen, China.,School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Xiujin Zhang
- BE/Phase I Clinical Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Chao Zheng
- BE/Phase I Clinical Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Lijun Zhu
- Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The 3rd Affiliated Hospital of Xiangya Medical Institute, Central South University, Changsha, China
| | - Minfeng Zhu
- School of Mathematics and Statistics, Central South University, Changsha, China
| | - Zeneng Cheng
- School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Xi Luo
- BE/Phase I Clinical Center, The First Affiliated Hospital of Xiamen University, Xiamen, China.,Faculty of Medicine, School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China
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26
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Yan L, Yang ZQ, Shi YY, Ren J, Yang CL, Wan ZL, Bai YJ, Luo LM, Wang LL, Li Y. Effects of Wuzhi Capsules on Blood Concentration of Tacrolimus in Renal Transplant Recipients. Ann Transplant 2019; 24:594-604. [PMID: 31712547 PMCID: PMC6873908 DOI: 10.12659/aot.918980] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tacrolimus is a widely used immunosuppressant in renal transplant recipients. It was demonstrated in rats and healthy volunteers that Wuzhi capsules could inhibit metabolism and maintain blood concentration of tacrolimus. However, there are no clinical studies of Wuzhi capsules in renal transplant recipients. This research aimed to assess the effect of Wuzhi capsules on the blood concentration of tacrolimus in renal transplant recipients. MATERIAL AND METHODS A total of 158 Chinese renal transplant recipients receiving tacrolimus with or without Wuzhi capsules were included in this retrospective study. The cohort study included 126 recipients, with 86 recipients receiving Wuzhi capsules (WZCs) and the other 40 recipients not receiving WZCs. Another 32 recipients were involved in a self-control study. RESULTS Dose- and body weight-adjusted trough concentrations (C0/D/W) of tacrolimus in the WZC group were found to be significantly higher than that in the non-WZC group (P<0.05). The improvement of C0/D/W by administration of Wuzhi capsules was more significant in CYP3A5 expressers than in non-expressers following subgroup analysis. Furthermore, the WZC group had a remarkably higher proportion of subjects who reached target tacrolimus concentration than in the non-WZC group, both in CYP3A5 expressers (P=0.01) and non-expressers (P<0.001). Multiple linear regression analysis and self-control analysis confirmed the positive impact of Wuzhi capsules on tacrolimus concentration (P<0.001). CONCLUSIONS Wuzhi capsules can increase tacrolimus trough concentration without adverse effects on allograft function, especially in CYP3A5 expressers. Efficient and convenient immunosuppressive effects on renal transplant recipients can be achieved by treatment including administration of Wuzhi capsules.
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Affiliation(s)
- Lin Yan
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Zhi-Qiang Yang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Yun-Ying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Jing Ren
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Cui-Li Yang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Zheng-Li Wan
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Yang-Juan Bai
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Li-Mei Luo
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Lan-Lan Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
| | - Yi Li
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R.China
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Wang D, Chen X, Fu M, Xu H, Li Z. Tacrolimus increases the expression level of the chemokine receptor CXCR2 to promote renal fibrosis progression. Int J Mol Med 2019; 44:2181-2188. [PMID: 31638188 PMCID: PMC6844638 DOI: 10.3892/ijmm.2019.4368] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/24/2019] [Indexed: 12/31/2022] Open
Abstract
Tacrolimus is one of the most used and effective immunosuppressive agents currently available in the clinic; however, its use is limited by nephrotoxicity, which is the main secondary effect of this drug. The mechanisms underlying tacrolimus-induced nephrotoxicity remain unknown. The present study aimed to investigate the mechanism underlying tacrolimus-induced nephrotoxicity and to identify novel potential targets. Masson staining, Sirius red staining and periodic acid-silver methenamine staining were used to observe kidney pathological changes. Immunohistochemical and immunofluorescent analyses were performed to examine the expression levels of vimentin, E-cadherin and α-smooth muscle actin (α-SMA). Transcriptomics and bioinformatics analyses were performed to investigate the nephrotoxicity mechanism induced by tacrolimus using RNA-sequencing, differentially expressed genes identification and annotation, and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis. The present results demonstrated that compared with the normal control group, the tacrolimus nephrotoxicity group exhibited severe renal fibrosis (P<0.05), upregulated vimentin (P<0.01), downregulated E-cadherin (P<0.05) and upregulated α-SMA (P<0.01). Transcriptomics and bioinformatics analyses identified the pathway 'cytokine-cytokine receptor interaction' as the most significantly enriched (P<0.05). Moreover, KEGG pathway enrichment analysis identified that tacrolimus increased the expression levels of chemokine (C-X-C) motif ligand (CXCL)1, CXCL2 and CXCL3 and the chemokine receptor C-X-C chemokine receptor type 2 (CXCR2). Collectively, the present study suggested that tacrolimus increases the level of chemokine receptor CXCR2 to promote renal fibrosis progression, which is one of the potential mechanisms underlying tacrolimus-induced nephrotoxicity.
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Affiliation(s)
- Dongdong Wang
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Xiao Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Meng Fu
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Zhiping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
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Tajima S, Yamamoto N, Masuda S. Clinical prospects of biomarkers for the early detection and/or prediction of organ injury associated with pharmacotherapy. Biochem Pharmacol 2019; 170:113664. [PMID: 31606409 DOI: 10.1016/j.bcp.2019.113664] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/08/2019] [Indexed: 12/31/2022]
Abstract
Several biomarkers are used to monitor organ damage caused by drug toxicity. Traditional markers of kidney function, such as serum creatinine and blood urea nitrogen are commonly used to estimate glomerular filtration rate. However, these markers have several limitations including poor specificity and sensitivity. A number of serum and urine biomarkers have recently been described to detect kidney damage caused by drugs such as cisplatin, gentamicin, vancomycin, and tacrolimus. Neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty acid-binding protein (L-FABP), kidney injury molecule-1 (KIM-1), monocyte chemotactic protein-1 (MCP-1), and cystatin C have been identified as biomarkers for early kidney damage. Hy's Law is widely used as to predict a high risk of severe drug-induced liver injury caused by drugs such as acetaminophen. Recent reports have indicated that glutamate dehydrogenase (GLDH), high-mobility group box 1 (HMGB-1), Keratin-18 (k18), MicroRNA-122 and ornithine carbamoyltransferase (OCT) are more sensitive markers of hepatotoxicity compared to the traditional markers including the blood levels of amiotransferases and total bilirubin. Additionally, the rapid development of proteomic technologies in biofluids and tissue provides a new multi-marker panel, leading to the discovery of more sensitive biomarkers. In this review, an update topics of biomarkers for the detection of kidney or liver injury associated with pharmacotherapy.
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Affiliation(s)
- Soichiro Tajima
- Department of Pharmacy, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Nanae Yamamoto
- Department of Pharmacy, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, Fukuoka 812-8582, Japan; Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka 812-8582, Japan; Department of Pharmacy, International University of Health and Welfare Narita Hospital, Japan; Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, International University of Health and Welfare Narita Hospital, Japan.
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Comparison of 4 Commercial Immunoassays Used in Measuring the Concentration of Tacrolimus in Blood and Their Cross-Reactivity to Its Metabolites. Ther Drug Monit 2019; 42:400-406. [PMID: 31568181 DOI: 10.1097/ftd.0000000000000696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring of tacrolimus is necessary for appropriate dose adjustment for a successful immunosuppressive therapy. Several commercial immunoassays are available for tacrolimus measurements. This study aimed at simultaneously evaluating the analytical performances of 4 such immunoassays, using liquid chromatography-tandem mass spectrometry (LC-MS/MS) as a standard. For the first time, cross-reactivity to tacrolimus metabolites was assessed at concentrations frequently observed in clinical settings, as opposed to the higher concentrations tested by assay manufacturers. METHODS An affinity column-mediated immunoassay (ACMIA), using upgraded flex reagents; released in 2015, a chemiluminescence immunoassay (CLIA), an electrochemiluminescence immunoassay (ECLIA), and a latex agglutination turbidimetric immunoassay (LTIA) were evaluated using frozen whole blood samples collected from transplantation patients. Cross-reactivities to 3 major tacrolimus metabolites (13-O-demethyl-tacrolimus [M-I], 31-O-demethyl-tacrolimus [M-II], and 15-O-demethyl-tacrolimus [M-III]) were evaluated. RESULTS Each immunoassay correlated well with LC-MS/MS, and the Pearson's correlation coefficients (R) were 0.974, 0.977, 0.978, and 0.902 for ACMIA, CLIA, ECLIA, and LTIA, respectively. Using Bland-Altman difference plots to compare the immunoassays with LC-MS/MS, the calculated average biases were -6.73%, 6.07%, 7.46%, and 12.27% for ACMIA, CLIA, ECLIA, and LTIA, respectively. The cross-reactivities of ACMIA to the tacrolimus metabolites M-II and M-III were 81% and 78%, respectively, when blood was spiked at 2 ng/mL, and 94% and 68%, respectively, when it was spiked at 5 ng/mL. CONCLUSIONS Each immunoassay was useful, but had its own characteristics. ACMIA cross-reactivities to M-II and M-III were much higher than the respective 18% and 15% reported on its package insert, suggesting that cross-reactivity should be examined at clinically relevant concentrations.
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30
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Largeau B, Guellec CBL, Longuet H, Lesne P, Bouvarel A, Préteseille L, Marquet P, Halimi JM, Büchler M, Gatault P, Noble J. Comparison of Tacrolimus Starting Doses Based on CYP3A5 Phenotype or Genotype in Kidney Transplant Recipients. Prog Transplant 2019; 29:300-308. [PMID: 31514576 DOI: 10.1177/1526924819873905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Selection of expected phenotypes (ie, expressers/non-expressers) is currently used in CYP3A5*3 genotype-based tacrolimus dosing. The authors assessed whether a dosing regimen based on the 3 CYP3A5 genotypes may reduce the occurrence of inadequate exposure. METHODS Tacrolimus whole blood trough levels (C 0) were retrieved from a retrospective cohort of 100 kidney transplant recipients treated with a starting dose of 0.15 (non-expressers) or 0.30 (expressers) mg/kg/d. The authors evaluated the occurrence of overexposures (12 < C 0 < 20 ng/mL) or toxic concentrations (C 0 ≥ 20 ng/mL). These results were used to set up a new strategy based on the 3 distinct CYP3A5 genotypes, which relevance was evaluated in a prospective cohort of 107 patients. RESULTS In the retrospective cohort, non-expressers exhibited frequent overexposure (63.6%) or toxic C 0 (20.8%). Among expressers, none of the homozygous *1 carriers exhibited overexposure contrary to 25% of the heterozygotes. Based on these results, new tacrolimus starting doses were set at 0.10, 0.20, and 0.30 mg/kg/d for CYP3A5*3/*3, CYP3A5*1/*3, and CYP3A5*1/*1 genotypes, respectively. Tacrolimus overexposure was reduced in the CYP3A5*3/*3 group (63.6% vs 40%, P = .0038). None of the heterozygous patients exhibited toxic tacrolimus C 0. Clinical outcomes were not different between the 2 periods, whatever the genotype. Our results indicate that the best tacrolimus exposure was obtained for doses of 0.10, 0.20, and 0.20 mg/kg/d for CYP3A5*3/3, CYP3A5*1/*3, and CYP3A5*1/*1, respectively. CONCLUSIONS Our results confirm that selecting tacrolimus dosing regimen according to the expected phenotype is appropriate, but that lower than currently recommended doses may be preferable.
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Affiliation(s)
- Bérenger Largeau
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Chantal Barin-Le Guellec
- Université de Tours, Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Hélène Longuet
- CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Philippe Lesne
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Antoine Bouvarel
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Laura Préteseille
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Pierre Marquet
- Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHU de Limoges, Service de Pharmacologie et Toxicologie, FHU SUPORT, Limoges, France
| | - Jean-Michel Halimi
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Matthias Büchler
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Philippe Gatault
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Johan Noble
- CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
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Nowicka M, Górska M, Nowicka Z, Edyko K, Edyko P, Wiślicki S, Zawiasa-Bryszewska A, Strzelczyk J, Matych J, Kurnatowska I. Tacrolimus: Influence of the Posttransplant Concentration/Dose Ratio on Kidney Graft Function in a Two-Year Follow-Up. Kidney Blood Press Res 2019; 44:1075-1088. [PMID: 31522184 DOI: 10.1159/000502290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Tacrolimus (TAC) metabolism rate has the potential to impact graft function after kidney transplantation (KTx). We aimed to analyze the relationship between the early post-KTx TAC C/D ratio (blood trough concentration normalized by total daily dose) and kidney graft function in a 2-year follow-up. METHODS We retrospectively analyzed data from 101 post-KTx patients at 3, 6, 12, and 24 months after KTx to identify the C/D ratio cutoff value optimal for dividing patients into fast and slow TAC metabolizers. We investigated the relationship between their TAC metabolism rate and graft function. RESULTS Patients were divided based on the TAC C/D ratio at 6 months after KTx of 1.47 ng/mL * 1 mg. Fast metabolizers (C/D ratio <1.47 ng/mL * 1 mg) presented with significantly worse graft function throughout the whole study period (p < 0.05 at each timepoint) and were significantly less likely to develop good graft function (estimated glomerular filtration rate ≥45 mL/min/1.73 m2) than slow metabolizers. Our model based on donor and recipient age, recipient sex and slow/fast metabolism status allowed for identification of patients with compromised graft function in 2-year follow-up with 66.7% sensitivity and 94.6% specificity. CONCLUSION Estimating TAC C/D ratio at 6 months post-KTx might help identify patients at risk of developing deteriorated graft function in a 2-year follow-up.
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Affiliation(s)
- Maja Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Monika Górska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Zuzanna Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Krzysztof Edyko
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Piotr Edyko
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Sebastian Wiślicki
- Clinical Department of Anesthesiology and Intensive Care and Pain Management, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Anna Zawiasa-Bryszewska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Janusz Strzelczyk
- Department of General and Transplant Surgery, Medical University of Lodz, Lodz, Poland
| | - Józef Matych
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Ilona Kurnatowska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland, .,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland,
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Wang D, Chen X, Fu M, Xu H, Li Z. Pharmacogenomics analysis in Chinese pediatric liver transplantation patients with renal toxicity induced by tacrolimus. Xenobiotica 2019; 50:488-493. [PMID: 31379240 DOI: 10.1080/00498254.2019.1652782] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Survival for pediatric liver transplantation patients is limited by nephrotoxicity of calcineurin inhibitors tacrolimus. The present study was to explore the association of genetic factors with nephrotoxicity of pediatric liver transplantation patients treated with tacrolimus.Chinese pediatric liver transplantation patients under tacrolimus therapy between March 2014 and August 2018 from Children's Hospital of Fudan University were retrospectively analyzed. A total of 15 patients, including 6 patients with nephrotoxicity induced by tacrolimus and 9 patients without nephrotoxicity, were detected by pharmacogenomics (PGxOne®160). Demographic characteristics and laboratory testing were collected from medical logs. Tacrolimus blood concentrations were extracted from therapeutic drug monitoring (TDM) documents.The risk of renal toxicity induced by tacrolimus in Chinese pediatric liver transplantation patients were positively associated with T allele of cytochrome P450 1A2 (CYP1A2) rs2470890 (RR = 2.857, 95% confidence interval = [1.392-5.863]), A allele of dopamine D2 (DRD2) rs1076560 (RR = 4.375, 95% confidence interval = [1.148-16.676]), T allele of paraoxonase-1 (PON1) rs662 (RR = 2.800, 95% confidence interval= [1.184-6.622]), respectively.Pharmacogenomics analysis in Chinese pediatric liver transplantation patients with renal toxicity induced by tacrolimus was firstly reported. The SNPs in 3 genes (CYP1A2, DRD2, and PON1) were associated with risk of tacrolimus-induced nephrotoxicity.
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Affiliation(s)
- Dongdong Wang
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Meng Fu
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
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33
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Recent Topics on The Mechanisms of Immunosuppressive Therapy-Related Neurotoxicities. Int J Mol Sci 2019; 20:ijms20133210. [PMID: 31261959 PMCID: PMC6651704 DOI: 10.3390/ijms20133210] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023] Open
Abstract
Although transplantation procedures have been developed for patients with end-stage hepatic insufficiency or other diseases, allograft rejection still threatens patient health and lifespan. Over the last few decades, the emergence of immunosuppressive agents such as calcineurin inhibitors (CNIs) and mammalian target of rapamycin (mTOR) inhibitors have strikingly increased graft survival. Unfortunately, immunosuppressive agent-related neurotoxicity commonly occurs in clinical practice, with the majority of neurotoxicity cases caused by CNIs. The possible mechanisms through which CNIs cause neurotoxicity include increasing the permeability or injury of the blood–brain barrier, alterations of mitochondrial function, and alterations in the electrophysiological state. Other immunosuppressants can also induce neuropsychiatric complications. For example, mTOR inhibitors induce seizures, mycophenolate mofetil induces depression and headaches, methotrexate affects the central nervous system, the mouse monoclonal immunoglobulin G2 antibody (used against the cluster of differentiation 3) also induces headaches, and patients using corticosteroids usually experience cognitive alteration. Therapeutic drug monitoring, individual therapy based on pharmacogenetics, and early recognition of symptoms help reduce neurotoxic events considerably. Once neurotoxicity occurs, a reduction in the drug dosage, switching to other immunosuppressants, combination therapy with drugs used to treat the neuropsychiatric manifestation, or blood purification therapy have proven to be effective against neurotoxicity. In this review, we summarize recent topics on the mechanisms of immunosuppressive drug-related neurotoxicity. In addition, information about the neuroprotective effects of several immunosuppressants is also discussed.
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Neutrophil Gelatinase-Associated Lipocalin Is Not Associated with Tacrolimus-Induced Acute Kidney Injury in Liver Transplant Patients Who Received Mycophenolate Mofetil with Delayed Introduction of Tacrolimus. Int J Mol Sci 2019; 20:ijms20123103. [PMID: 31242630 PMCID: PMC6627315 DOI: 10.3390/ijms20123103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/22/2019] [Accepted: 06/23/2019] [Indexed: 01/07/2023] Open
Abstract
Tacrolimus is widely used as an immunosuppressant in liver transplantation, and tacrolimus-induced acute kidney injury (AKI) is a serious complication. The urinary neutrophil gelatinase-associated lipocalin (NGAL) level has been linked to tacrolimus-induced AKI in patients starting tacrolimus treatment the morning after liver transplantation. Here we tested this association using a different immunosuppression protocol: Mycophenolate mofetil administration beginning on Postoperative Day 1 and tacrolimus administration beginning on Postoperative Day 2 or 3. Urine samples were collected from 26 living donor liver transplant recipients before (Postoperative Day 1) and after (Postoperative Day 7 or 14) tacrolimus administration. NGAL levels were measured via enzyme-linked immunosorbent assays, as were those of three additional urinary biomarkers for kidney diseases: Monocyte chemotactic protein-1 (MCP-1), liver-type fatty acid-binding protein (L-FABP), and human epididymis secretory protein 4 (HE4). HE4 levels after tacrolimus administration were significantly higher in patients who developed AKI (n = 6) than in those who did not (n = 20), whereas NGAL, MCP-1, and L-FABP levels did not differ significantly before or after tacrolimus administration. These findings indicate that NGAL may not be a universal biomarker of AKI in tacrolimus-treated liver transplant recipients. To reduce the likelihood of tacrolimus-induced AKI, our immunosuppression protocol is recommended.
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35
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Itohara K, Yano I, Tsuzuki T, Uesugi M, Nakagawa S, Yonezawa A, Okajima H, Kaido T, Uemoto S, Matsubara K. A Minimal Physiologically-Based Pharmacokinetic Model for Tacrolimus in Living-Donor Liver Transplantation: Perspectives Related to Liver Regeneration and the cytochrome P450 3A5 (CYP3A5) Genotype. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:587-595. [PMID: 31087501 PMCID: PMC6709420 DOI: 10.1002/psp4.12420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/19/2019] [Indexed: 12/20/2022]
Abstract
In adult patients after living‐donor liver transplantation, postoperative days and the cytochrome P450 3A5 (CYP3A5) genotype are known to affect tacrolimus pharmacokinetics. In this study, we constructed a physiologically‐based pharmacokinetic model adapted to the clinical data and evaluated the contribution of liver regeneration as well as hepatic and intestine CYP3A5 genotypes on tacrolimus pharmacokinetics. As a result, liver function recovered immediately and affected the total body clearance of tacrolimus only during a limited period after living‐donor liver transplantation. The clearance was about 1.35‐fold higher in the recipients who had a liver with the CYP3A5*1 allele than in those with the CYP3A5*3/*3 genotype, whereas bioavailability was ~0.7‐fold higher in the recipients who had intestines with the CYP3A5*1 allele than those with CYP3A5*3/*3. In conclusion, the constructed physiologically‐based pharmacokinetic model clarified that the oral clearance of tacrolimus was affected by the CYP3A5 genotypes in both the liver and intestine to the same extent.
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Affiliation(s)
- Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan.,Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan
| | - Ikuko Yano
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan.,Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Tetsunori Tsuzuki
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Miwa Uesugi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan.,Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
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Liu Y, Zhang C, Li L, Ou B, Yuan L, Zhang T, Fan J, Peng Z. Genome-Wide Association Study of Tacrolimus Pharmacokinetics Identifies Novel Single Nucleotide Polymorphisms in the Convalescence and Stabilization Periods of Post-transplant Liver Function. Front Genet 2019; 10:528. [PMID: 31214251 PMCID: PMC6554639 DOI: 10.3389/fgene.2019.00528] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/14/2019] [Indexed: 12/15/2022] Open
Abstract
After liver transplantation, the liver function of a patient is gradually restored over a period of time that can be divided into a convalescence period (CP) and a stabilizing period (SP). The plasma concentration of tacrolimus, an immunosuppressant commonly used to prevent organ rejection, varies as a result of variations in its metabolism. The effects of genetic and clinical factors on the plasma concentration of tacrolimus appear to differ in the CP and SP. To establish a model explaining the variation in tacrolimus trough concentration between individuals in the CP and SP, we conducted a retrospective, single-center, discovery study of 115 pairs of patients (115 donors and 115 matched recipients) who had undergone liver transplantation. Donors and recipients were genotyped by a genome-wide association study (GWAS) using an exome chip. Novel exons were identified that influenced tacrolimus trough concentrations and were verified with bootstrap analysis. In donors, two single-nucleotide polymorphisms showed an effect on the CP (rs1927321, rs1057192) and four showed an effect on the SP (rs776746, rs2667662, rs7980521, rs4903096); in recipients, two single-nucleotide polymorphisms showed an effect in the SP (rs7828796, rs776746). Genetic factors played a crucial role in tacrolimus metabolism, accounting for 44.8% in the SP, which was higher than previously reported. In addition, we found that CYP3A5, which is known to affect the metabolism of tacrolimus, only influenced tacrolimus pharmacokinetics in the SP.
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Affiliation(s)
- Yuan Liu
- Department of Hepatobiliary Pancreatic Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chengdong Zhang
- State Key Laboratory of Genetic Engineering, School of Life Sciences, Fudan University, Shanghai, China
| | - Lei Li
- Department of Hepatobiliary Pancreatic Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Baochi Ou
- Department of Hepatobiliary Pancreatic Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Liyun Yuan
- Key Lab of Computational Biology, CAS-MPG Partner Institute for Computational Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Tao Zhang
- Department of Organ Transplant, The Second Affiliated Hospital to Guangzhou Medical University, Guangzhou, China
| | - Junwei Fan
- Department of Hepatobiliary Pancreatic Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhihai Peng
- Department of Hepatobiliary Pancreatic Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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37
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Impact of CYP3A5, POR, and CYP2C19 Polymorphisms on Trough Concentration to Dose Ratio of Tacrolimus in Allogeneic Hematopoietic Stem Cell Transplantation. Int J Mol Sci 2019; 20:ijms20102413. [PMID: 31096684 PMCID: PMC6566597 DOI: 10.3390/ijms20102413] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/09/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022] Open
Abstract
Single nucleotide polymorphisms in drug-metabolizing genes may affect tacrolimus pharmacokinetics. Here, we investigated the influence of genotypes of CYP3A5, CYP2C19, and POR on the concentration/dose (C/D) ratio of tacrolimus and episodes of acute graft-versus-host disease (GVHD) in Japanese recipients of allogeneic hematopoietic stem cell transplantation (HSCT). Thirty-six patients receiving the first HSCT using tacrolimus-based GVHD prophylaxis were enrolled with written informed consent. During continuous intravenous infusion, HSCT recipients carrying the CYP3A5*1 allele, particularly those with at least one POR*28 allele, had a significantly lower tacrolimus C/D ratio throughout all three post-HSCT weeks compared to that in recipients with POR*1/*1 (p < 0.05). The CYP3A5*3/*3 genotype and the concomitant use of voriconazole were independent predictors of an increased tacrolimus C/D ratio during the switch from continuous intravenous infusion to oral administration (p < 0.05). In recipients receiving concomitant administration of voriconazole, our results suggest an impact of not only CYP3A5 and CYP2C19 genotypes, but also plasma voriconazole concentration. Although switching from intravenous to oral administration at a ratio of 1:5 was seemingly appropriate in recipients with CYP3A5*1, a lower conversion ratio (1:2-3) was appropriate in recipients with CYP3A5*3/*3. Our results suggest that CYP3A5, POR, and CYP2C19 polymorphisms are useful biomarkers for individualized dosage adjustment of tacrolimus in HSCT recipients.
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Matsuoka S, Tsutsumi Y, Kikuchi R, Ito S, Teshima T. Gene Polymorphism of Tacrolimus-Metabolizing Enzymes Associated With Impaired Absorption of Tacrolimus Following Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report. Transplant Proc 2019; 51:998-1001. [PMID: 30979494 DOI: 10.1016/j.transproceed.2019.01.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 12/25/2018] [Accepted: 01/17/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To elucidate the mechanisms by which orally administered tacrolimus was not absorbed in a patient following allogeneic hematopoietic stem cell transplantation. CLINICAL COURSE A 17-year-old girl with acute myeloid leukemia underwent HLA-haploidentical peripheral blood stem cell transplantation following fludarabine, busulfan, and total-body irradiation. Graft-vs-host disease prophylaxis was post-transplant cyclophosphamide, followed by intravenous tacrolimus and mycophenolate mofetil. When tacrolimus was switched to oral administration, its blood level declined rapidly, resulting in development of acute graft-vs-host disease, which was ameliorated by switching back to intravenous administration. METHODS/RESULTS To elucidate if impaired tacrolimus absorption could be related to genetic polymorphism of tacrolimus-metabolizing enzymes, we analyzed gene polymorphisms of cytochrome P450 3A4, cytochrome P450 3A5, and multidrug resistance 1 (MDR1). The patient had wild-type cytochrome P450 3A4 (*1/*1) and variant-type cytochrome P450 3A5 (*3/*3), while MDR1 genes (2677A/G, 3435C/C) were wild-type. CONCLUSION Wild-type MDR1 gene product P-glycoprotein expressed in the intestine reduces drug absorption from the gastrointestinal tract and may have contributed to low blood levels of tacrolimus in this patient when tacrolimus was orally administered.
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Affiliation(s)
- S Matsuoka
- Department of Hematology, Hakodate Municipal Hospital, Hakodate, Japan.
| | - Y Tsutsumi
- Department of Hematology, Hakodate Municipal Hospital, Hakodate, Japan
| | - R Kikuchi
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - S Ito
- Department of Hematology, Hakodate Municipal Hospital, Hakodate, Japan
| | - T Teshima
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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Mimura A, Yamaori S, Ikemura N, Katsuyama Y, Matsuzawa N, Ohmori S. Influence of azole antifungal drugs on blood tacrolimus levels after switching from intravenous tacrolimus to once-daily modified release tacrolimus in patients receiving allogeneic hematopoietic stem cell transplantation. J Clin Pharm Ther 2019; 44:565-571. [PMID: 30950099 DOI: 10.1111/jcpt.12834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/25/2019] [Accepted: 03/10/2019] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Azole antifungal drugs are often co-administered with tacrolimus after allogeneic hematopoietic stem cell transplantation (HSCT). However, the influence of azole antifungal drugs on variation in tacrolimus pharmacokinetics when switching from intravenous tacrolimus (Tac-iv) to once-daily modified release tacrolimus (Tac-MR) remains to be elucidated. This study was performed to evaluate the effects of oral azole antifungal drugs on variation in tacrolimus pharmacokinetics after conversion to Tac-MR in HSCT patients. METHODS Patients concomitantly receiving fluconazole (FLCZ) or voriconazole (VRCZ) along with tacrolimus were evaluated retrospectively. Blood tacrolimus concentrations before and after changing to oral administration were compared between FLCZ and VRCZ groups. RESULTS AND DISCUSSION A total of 52 patients (34 FLCZ and 18 VRCZ) were included in the analysis. There were no significant differences in the most recent daily dose (Div ) and blood level (Civ ) of Tac-iv, Civ /Div , and ratio of daily dose of tacrolimus on the first to second day after changing to Tac-MR (Dpo1-2 ) to Div between FLCZ and VRCZ groups (P > 0.2). The trough levels of tacrolimus on the first to second day after switching to Tac-MR (Cpo1-2 ) and on the third to fifth day after the switch (Cpo3-5 ) were significantly higher in the VRCZ group than the FLCZ group (P < 0.05). The values of (Civ /Div )/(Cpo1-2 /Dpo1-2 ) and (Civ /Div )/(Cpo3-5 /Dpo3-5 ) in the VRCZ group were significantly lower compared with those in the FLCZ group (P < 0.05). Furthermore, individual values of (Civ /Div )/(Cpo3-5 /Dpo3-5 ) in the FLCZ group varied widely. WHAT IS NEW AND CONCLUSION Voriconazole increased blood tacrolimus level more markedly than FLCZ after switching to Tac-MR, whereas FLCZ caused a large variation in tacrolimus blood level. These results suggest that therapeutic monitoring of tacrolimus after the switch may need to be performed carefully considering that orally co-administered VRCZ and FLCZ exhibit different change in blood tacrolimus level just after the switch.
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Affiliation(s)
- Akira Mimura
- Department of Pharmacy, Shinshu University Hospital, Matsumoto, Japan.,Department of Biochemical Pharmacology and Toxicology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Satoshi Yamaori
- Department of Pharmacy, Shinshu University Hospital, Matsumoto, Japan.,Department of Biochemical Pharmacology and Toxicology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Noriaki Ikemura
- Department of Pharmacy, Shinshu University Hospital, Matsumoto, Japan.,Department of Biochemical Pharmacology and Toxicology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | | | - Naoki Matsuzawa
- Department of Pharmacy, Shinshu University Hospital, Matsumoto, Japan
| | - Shigeru Ohmori
- Department of Pharmacy, Shinshu University Hospital, Matsumoto, Japan.,Department of Biochemical Pharmacology and Toxicology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
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40
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Tang J, Xu J, Zhang Y, Liu R, Liu M, Hu Y, Shao M, Zhu L, Cao S, Xin H, Feng G, Shang W, Meng X, Zhang L, Ming Y, Zhang W, Zhou G. Incorporation of Gene‐Environment Interaction Terms Improved the Predictive Accuracy of Tacrolimus Stable Dose Algorithms in Chinese Adult Renal Transplant Recipients. J Clin Pharmacol 2019; 59:890-899. [PMID: 30861159 DOI: 10.1002/jcph.1379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/02/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Jie Tang
- Department of Clinical Pharmacology, Xiangya HospitalCentral South University Hunan China
- Institute of Clinical PharmacologyCentral South UniversityHunan Key Laboratory of Pharmacogenetics Hunan China
| | - Jing Xu
- Department of Clinical Pharmacology, Xiangya HospitalCentral South University Hunan China
- Institute of Clinical PharmacologyCentral South UniversityHunan Key Laboratory of Pharmacogenetics Hunan China
| | - Yue‐Li Zhang
- Department of Clinical Pharmacology, Xiangya HospitalCentral South University Hunan China
- Institute of Clinical PharmacologyCentral South UniversityHunan Key Laboratory of Pharmacogenetics Hunan China
- The Affiliated Zhengzhou Central Hospital of Zhengzhou University Henan China
| | - Rong Liu
- Department of Clinical Pharmacology, Xiangya HospitalCentral South University Hunan China
- Institute of Clinical PharmacologyCentral South UniversityHunan Key Laboratory of Pharmacogenetics Hunan China
| | - Mou‐Ze Liu
- Department of Clinical Pharmacology, Xiangya HospitalCentral South University Hunan China
- Institute of Clinical PharmacologyCentral South UniversityHunan Key Laboratory of Pharmacogenetics Hunan China
| | - Yong‐Fang Hu
- Beijing Tsinghua Changgeng Hospital Beijing China
| | - Ming‐Jie Shao
- Research Center of Chinese Health Ministry of Transplantation Medicine Engineering and Technology, Third Affiliated HospitalCentral South University Hunan China
| | - Li‐Jun Zhu
- Research Center of Chinese Health Ministry of Transplantation Medicine Engineering and Technology, Third Affiliated HospitalCentral South University Hunan China
| | - Shan Cao
- Department of Clinical Pharmacology, Xiangya HospitalCentral South University Hunan China
- Institute of Clinical PharmacologyCentral South UniversityHunan Key Laboratory of Pharmacogenetics Hunan China
| | - Hua‐Wen Xin
- Department of Clinical PharmacologyWuhan General Hospital of Guangzhou Command Hubei China
| | - Gui‐Wen Feng
- Department of Renal TransplantationThe First Affiliated Hospital of Zhengzhou University Henan China
| | - Wen‐Jun Shang
- Department of Renal TransplantationThe First Affiliated Hospital of Zhengzhou University Henan China
| | - Xiang‐Guang Meng
- School of Basic Medical SciencesZhengzhou University Henan China
| | - Li‐Rong Zhang
- School of Basic Medical SciencesZhengzhou University Henan China
| | - Ying‐Zi Ming
- Research Center of Chinese Health Ministry of Transplantation Medicine Engineering and Technology, Third Affiliated HospitalCentral South University Hunan China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya HospitalCentral South University Hunan China
- Institute of Clinical PharmacologyCentral South UniversityHunan Key Laboratory of Pharmacogenetics Hunan China
| | - Gan Zhou
- National Institution of Drug Clinical Trial, Xiangya HospitalCentral South University Changsha China
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41
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Okabayashi S, Kobayashi T, Saito E, Toyonaga T, Ozaki R, Sagami S, Nakano M, Tanaka J, Yagisawa K, Kuronuma S, Takeuchi O, Hibi T. Individualized treatment based on CYP3A5 single-nucleotide polymorphisms with tacrolimus in ulcerative colitis. Intest Res 2019; 17:218-226. [PMID: 30704156 PMCID: PMC6505090 DOI: 10.5217/ir.2018.00117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/05/2018] [Indexed: 12/19/2022] Open
Abstract
Background/Aims The pharmacokinetics of tacrolimus (TAC) is known to be largely influenced by single-nucleotide polymorphisms (SNPs) in CYP3A5. Patients starting TAC require careful dose adjustment, owing to the wide range of optimal dosages, depending on their CYP3A5 expression status. Here, we evaluated whether individualization of TAC dosages based on CYP3A5 SNPs would improve its therapeutic efficacy in ulcerative colitis. Methods Twenty-one patients were prospectively treated, with their initial dosage adjusted according to their CYP3A5 status (0.1, 0.15, and 0.2 mg/kg/day for CYP3A5*3/*3, CYP3A5*1/*3, and CYP3A5*1/*1, respectively). Their clinical outcomes were compared with those of patients treated with a fixed dose (0.1 mg/kg/day). Results The first blood trough level of CYP3A5 expressors, CYP3A5*1/*3 or CYP3A5*1/*1, and the overall rate in achieving the target blood trough level within a week in the individualized-dose group were significantly higher than those in the fixed-dose group (5.15±2.33 ng/mL vs. 9.63±0.79 ng/mL, P=0.035 and 12.5% vs. 66.7%, P=0.01). The remission rate at 2 weeks in the expressors was as high as that in the nonexpressors, CYP3A5*3/*3, in the individualized-dose group. Conclusions Individualized TAC treatment is effective against ulcerative colitis regardless of the CYP3A5 genotype.
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Affiliation(s)
- Shinji Okabayashi
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Eiko Saito
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Takahiko Toyonaga
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Ryo Ozaki
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Shintaro Sagami
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Masaru Nakano
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Junichi Tanaka
- Department of Rheumatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Keiji Yagisawa
- Department of Pharmacy, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Satoshi Kuronuma
- Biomedical Laboratory, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Osamu Takeuchi
- Biomedical Laboratory, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Department of Research, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Abstract
The standard therapy for decompensated end-stage chronic liver disease of any etiology and acute fulminant hepatic failure is liver transplantation (LT). Advances in immunosuppressive therapy decreased the rates of acute and chronic rejections. Thus, graft and patient survivals have significantly improved. However, long-term adverse effects of prolonged use of immunosuppressive agents such as malignancies, opportunistic infections, metabolic disorders, and other organ toxicities have now become a major concern. Consequently, alternative approaches are needed to deescalate the customary drugs and their side effects. Therapy must be individualized and additional preventive measures should be taken by patients with particular risk factors or predisposed to certain adverse effects. Current opinion favors a combination of agents with different mechanism of actions and toxicity profiles. Corticosteroids are employed in immediate and early postoperative period. Although they have a pronounced side effect profile, calcineurin inhibitors (CNIs) are still the backbone of early and late phase immunosuppressive regimens because of their proved efficacy. Antimetabolites are frequent choices for steroid and/or CNI-sparing strategies. Studies also have established a role for mammalian target of rapamycin (mTOR) inhibitors in specific groups of recipients. Biologic agents are a hot topic of interest and made their way into current strategies for induction. Agents extrapolated from other transplantation or immunologic experience are being evaluated.
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Affiliation(s)
- Burcak E Tasdogan
- Department of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle Ma
- Department of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cem Simsek
- Department of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Behnam Saberi
- Department of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Ahmet Gurakar
- Department of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Stepensky D. Pharmacokinetics of Toxin-Derived Peptide Drugs. Toxins (Basel) 2018; 10:toxins10110483. [PMID: 30463321 PMCID: PMC6266565 DOI: 10.3390/toxins10110483] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/14/2018] [Accepted: 11/16/2018] [Indexed: 12/20/2022] Open
Abstract
Toxins and venoms produced by different organisms contain peptides that have evolved to have highly selective and potent pharmacological effects on specific targets for protection and predation. Several toxin-derived peptides have become drugs and are used for the management of diabetes, hypertension, chronic pain, and other medical conditions. Despite the similarity in their composition (amino acids as the building blocks), toxin-derived peptide drugs have very profound differences in their structure and conformation, in their physicochemical properties (that affect solubility, stability, etc.), and subsequently in their pharmacokinetics (the processes of absorption, distribution, metabolism, and elimination following their administration to patients). This review summarizes and critically analyzes the pharmacokinetic properties of toxin-derived peptide drugs: (1) the relationship between the chemical structure, physicochemical properties, and the pharmacokinetics of the specific drugs, (2) the major pharmacokinetic properties and parameters of these drugs, and (3) the major pharmacokinetic variability factors of the individual drugs. The structural properties of toxin-derived peptides affect their pharmacokinetics and pose some limitations on their clinical use. These properties should be taken into account during the development of new toxin-derived peptide drugs, and for the efficient and safe use of the clinically approved drugs from this group in the individual patients.
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Affiliation(s)
- David Stepensky
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 84105, Israel.
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Zhang X, Lin G, Tan L, Li J. Current progress of tacrolimus dosing in solid organ transplant recipients: Pharmacogenetic considerations. Biomed Pharmacother 2018; 102:107-114. [DOI: 10.1016/j.biopha.2018.03.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/27/2018] [Accepted: 03/09/2018] [Indexed: 12/11/2022] Open
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Liu J, Ouyang Y, Chen D, Yao B, Lin D, Li Z, Zang Y, Liu H, Fu X. Donor and recipient P450 gene polymorphisms influence individual pharmacological effects of tacrolimus in Chinese liver transplantation patients. Int Immunopharmacol 2018; 57:18-24. [PMID: 29454235 DOI: 10.1016/j.intimp.2018.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 12/16/2022]
Abstract
The immunosuppressant drug tacrolimus (Tac) used for the prevention of immunological rejection is a metabolic substrate of cytochrome P450 enzymes. This study was designed to evaluate the short-term and long-term potential influence of single-nucleotide polymorphisms (SNPs) in CYP450 genes of liver transplant (LT) recipients as well as the donors on individual pharmacological effects of Tac and to guide individualized-medication from the perspective of pharmacogenomics. Twenty-one SNPs of the CYP450 gene were genotyped for both recipients and donors in 373 LT patients receiving Tac-based immunosuppressants. The Tac concentration/dosage ratio (C/D) was evaluated from the initial medication until one year after LT. The C/D ratio was significantly higher when the donor and/or recipient genotype of CYP3A5 rs776746 was G/G or rs15524 was T/T or rs4646450 was C/C all through one year after transplantation. Comparing the effect of donor gene variants of rs776746, rs15524, and rs4646450 on Tac C/D ratios with the recipients, statistically significant differences were found between the donor T/T group and the recipient T/T group in rs15524 at 1 month and 6 months, and at 6 months, the donor C/C group differed from the recipient C/C group in rs4646450. In conclusion, rs776746, rs15524, and rs4646450 of CYP3A5 had a significant influence on Tac pharmacological effects for both the initial use and long-term use. The donor liver genotype and the recipient intestine genotype contribute almost equally in the short-term, but the donor genotype had a greater effect than the recipient genotype at 6 months. Personalized Tac treatment after LT should be based on the CYP3A5 genotype.
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Affiliation(s)
- Jianyu Liu
- Institute of Transplant Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yabo Ouyang
- Institute of Hepatology, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Dexi Chen
- Institute of Transplant Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bo Yao
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dongdong Lin
- Department of General Surgery, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Zhiqiang Li
- Institute of Transplant Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yunjin Zang
- Institute of Transplant Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Huan Liu
- Institute of Transplant Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoyue Fu
- Institute of Transplant Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
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Kaneko T, Arai M, Watanabe A, Tsuruoka S. Effectiveness of Measuring Genetic Polymorphisms in Metabolizing Enzymes of Tacrolimus within One Medical Facility. J NIPPON MED SCH 2017; 84:274-279. [PMID: 29279557 DOI: 10.1272/jnms.84.274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Because genetic polymorphisms cause diverse activity in drug metabolizing enzymes, drug concentrations in the blood may be variable among patients. We analyzed the genotypes of CYP3A5 and MDR1, and investigated their relationship with whole blood drug concentrations. METHODS Eight patients were administered an oral dose of tacrolimus for one week or longer prior to enrollment in this study. Whole blood concentrations for tacrolimus were measured 12 hours post oral administration, on the same day as genotyping, within our hospital using a fully automated gene analyzer. The procedures became so rapid that collection of blood samples could be completed within the same day (approximately one hour). RESULTS The genotype frequency of CYP3A5 was *3/*3 in five patients, *1/*3 in two patients, and *1/*1 in one patient. All five patients with *3/*3 showed favorable increases in tacrolimus blood concentrations. In the two patients with *1/*3, an increase in tacrolimus blood concentration was not readily achieved in one patient, but increased favorably in the other patient. In the patient with *1/*1, tacrolimus was not detectable in the patient's blood. A favorable treatment effect was obtained by changing tacrolimus to cyclosporine. It is notable that genotypes in patients where tacrolimus was not detected in the blood were wild types: 2677G/G and 3435C/C in MDR1. CONCLUSIONS The measurement of genetic polymorphisms in metabolizing enzymes of tacrolimus, within one medical facility, is applicable for the selection of immunosuppressants and individual dosing for the treatment of autoimmune disease.
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Affiliation(s)
- Tomohiro Kaneko
- Divisions of Nephrology, Nippon Medical School Tama Nagayama Hospital
| | - Momoko Arai
- Divisions of Nephrology, Nippon Medical School Tama Nagayama Hospital
| | - Atsushi Watanabe
- Division of Personalized Genetic Medicine, Nippon Medical School Hospital
| | - Shuichi Tsuruoka
- Divisions of Nephrology, Department of Internal Medicine, Nippon Medical School
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Sun B, Guo Y, Gao J, Shi W, Fan G, Li X, Qiu J, Qin Y, Liu G. Influence of CYP3A and ABCB1 polymorphisms on cyclosporine concentrations in renal transplant recipients. Pharmacogenomics 2017; 18:1503-1513. [PMID: 28952408 DOI: 10.2217/pgs-2017-0127] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Aim: Cyclosporine is a substrate of CYP3A and ABCB1. This study examined the role of CYP3A and ABCB1 polymorphisms on cyclosporine pharmacokinetics in renal transplant recipients. Patients & methods: CYP3A and ABCB1 SNPs were detected in 521 recipients. The relationships of dose-adjusted concentrations with corresponding genotypes were investigated at the different terms. Results: CYP3A5 rs776746 and CYP3A7 rs10211 genotype affect C0/D at the short-term, medium-term and long-term after transplantation (p < 0.05). CYP3A7 rs2257401 genotype affects C2/D at the medium-term (p < 0.05). CYP3A4 rs4646437, CYP3A5 rs776746 and CYP3A7 rs2257401 genotype affect C2/D at the long-term (p < 0.05). There are no relationships between ABCB1 polymorphism and cyclosporine C/D. Conclusion: CYP3A genetic factors (rs776746, rs4646437, rs2257401 and rs10211) were varied in different stages after transplantation. The role of CYP3A7 in cyclosporine metabolism requires further study.
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Affiliation(s)
- Bo Sun
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Yankun Guo
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Junwei Gao
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Weifeng Shi
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Guorong Fan
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Xiaoyu Li
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Jianxin Qiu
- Department of Renal Transplantation & Urology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Yan Qin
- Department of Renal Transplantation & Urology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Gaolin Liu
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
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The combination of CYP3A4*22 and CYP3A5*3 single-nucleotide polymorphisms determines tacrolimus dose requirement after kidney transplantation. Pharmacogenet Genomics 2017; 27:313-322. [DOI: 10.1097/fpc.0000000000000296] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Li J, Chen S, Qin X, Fu Q, Bi H, Zhang Y, Wang X, Liu L, Wang C, Huang M. Wuzhi Tablet (Schisandra sphenanthera Extract) Is a Promising Tacrolimus-Sparing Agent for Renal Transplant Recipients Who Are CYP3A5 Expressers: a Two-Phase Prospective Study. Drug Metab Dispos 2017; 45:1114-1119. [DOI: 10.1124/dmd.117.076737] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/17/2017] [Indexed: 01/06/2023] Open
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50
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van Gelder T, Fischer L, Shihab F, Shipkova M. Optimizing everolimus exposure when combined with calcineurin inhibitors in solid organ transplantation. Transplant Rev (Orlando) 2017; 31:151-157. [DOI: 10.1016/j.trre.2017.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/13/2017] [Accepted: 02/21/2017] [Indexed: 01/05/2023]
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